A charge nurse on a mental health unit is receiving change of shift report for a group of clients. The charge nurse is working with an RN, an LPN, and assistive personnel (AP) from 0700 to 1900 and is reviewing client care assignments. Complete the following sentence by using the lists of options.

The charge nurse should first assess the client who has a 7-year history of major depressive disorder, whose friend reports the client has stopped taking their medication, and who is flat, withdrawn, cries all the time, sleeps all the time, and has extremely slowed movements, due to the risk of Select.

suicide

dehydration

infection

seizure

Answer and Explanation

The Correct Answer is A

Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.

Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.

Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.

Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is c.

Choice A reason: Providing the UAP with the infection control policy is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

Choice B reason: Offering to assist the UAP with the collection of the specimen is not the first action the charge nurse should take. The charge nurse should first address the UAP's fear and educate the UAP about HIV transmission and infection control measures.

Choice C reason: Determining the UAP's knowledge about HIV transmission is the first action the charge nurse should take. This will help the charge nurse identify any knowledge gaps or misconceptions the UAP may have and provide appropriate education and reassurance.

Choice D reason: Demonstrating the proper use of personal protective equipment is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.

A. Collect the client's urine output every 24 hours B. Administer the client's scheduled antitubercular medications C. Assist the client with speech therapy exercises D. Place the client on airborne precautions

Correct Answer is A

Explanation

Choice A reason: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.

Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.

Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.

Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Correct Answer is C

Explanation

A nurse is reviewing the provider's prescriptions for a client who has a positive sputum culture for tuberculosis. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is A

Explanation

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?

A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?

A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?

A nurse is teaching a client about implied consent. Which of the following information should the nurse include in the teaching?

A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?

A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?